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Role of Antibiotics in Open Fractures of the Finger

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Role of Antibiotics in Open Fractures of the Finger Vol. 15A, No. 5 September 1990 Fasciectomy for treatment qf Dupuyren’s diseaw 16. Hueston JT. ‘Firebreak’ grafts in Dupuytren’s contrac- 20 Honner R, Lamb DW, James JIP. Dupuytren’s contrac- ture. Aust N Z J Surg 1984;54:277-81. ture. long term results after fasiectomy. J Bone Joint Surg 17. Strickland JW. The coverage of difficult digital defects 1971;53B:240-6. with local rotation flaps. In: Strickland JW, Steichen WB, 21 Green TL, Strickland JW, Torstrick RF. The proximal eds. Difficult problems in hand surgery. St. Louis: The interphalangeal joint in Dupuytren’s contracture. In: CV Mosby Company, 1982:38&l. Strickland JW, Steichen WB, eds. Difficult problems in 18. Hueston JT. Limited fasciectomy for Dupuytren’s con- hand surgery. St. Louis: The CV Mosby Company, tracture. Plast Reconstr Surg 1961;27:569-85. 1982:414-18. 19. Zachariae-L. Extensive versus limited fasciectomy for Dupuytren’s contracture. Stand J Plast Reconstr Surg 1967;1:150-3. Role of antibiotics in open fractures of the finger The role of antibiotics was investigated prospectively in 91 open fractures of the finger. Antibiotics were administered to alternate patients with open phalangeal fractures. Only finger fractures distal to the metacarpophalangeal joint were included. Both groups were treated with aggressive surgical irrigation and debridement. In four patients in each group clinical signs of infection eventually developed; osteomyelitis did not develop in any patients, and no secondary surgical procedures were required in either group. This data indicates that vigorous irrigation and debridement is adequate primary treatment for open phalangeal fractures in fingers with intact digital arteries. (J HAND SURG1990;15A:761-4.) Mark D. Suprock, MD, Oklahoma City, Okla., John M. Hood, MD, and John D. Lubahn, MD, Erie, Pa. T he use of antibiotics in the treatment of tissue wounds in the upper extremity may be treated open fractures of the long bones is widely accepted as with local care alone without the increased risk of in- standard treatment and their effectiveness has been fection as shown in two separate studies by Grossman proven in random prospective studies by Patzakis and and colleagues’ and Thirlby and associates.6 Wavak’ associates’ and Gustilo and Anderson.’ Routine use of studied 100 consecutive hand injuries treated early with antibiotics in managing open fractures of the finger is antibiotics and noted an infection rate of approximately less common and there is a noticeable paucity of ob- 6%. jective literature to either support or refute their im- A review of five basic text books, Lister,’ Buck- portance . Gramcko,’ Beasley,” Flatt,” and Green” revealed a The effectiveness of antibiotics in grossly contami- unanimous recommendation that antibiotics not be rou- nated or marginally viable wounds has been established tinely used in the management of acute hand injuries. by Burkhalter et a1.3 and Cooney et a1.4 Isolated soft Coyle and Leddy,13 on the other hand, recommended that antibiotics are advisable for injuries in the distal finger. From the Orthopaedic Department, Hamot Medical Center, Erie, Pa. Two studies deal directly with the role of antibiotics Received for publication April 20, 1989; accepted in revised form in finger fractures. Sloan et al. I4 analyzed distal pha- Sept. 3, 1989. langeal fractures prospectively and found a 30% in- No benefits in any form have been received or will be received from crease in the incidence of infection when antibiotics a commercial party related directly or indirectly to the subject of this article. were not used. All amputations in this group, however, Reprint requests: John D. Lubahn, MD, 300 State St., Suite 205. were treated by primary closure with either free graft Erie, PA 16507. or V-Y flap. Peacock et a1.15 noted an increased risk of 311116987 side effects with antibiotics, as well as, a potential THE JOURNAL OF HAND SURGERY 761 The Journal of 762 Suprock, Hood, and Lubahn HAND SURGERY Fig. 1. A-D. A, Open fracture in an l&year-old right-handed man. B, Films before and after intraosseous wire fixation of the fracture. Fig. 1. Cont’d. C, Final result showing extension and flexion of the thumb 3 months later. D, Final result showing extension and flexion of the thumb three months later. cultivation of resistant organisms. They concluded that patients were followed-up in this study. The treatment use of antibiotics should be reserved for more serious for those receiving antibiotics was either a first gen- injuries or specifically identified infections. eration cephalosporin, dicloxacillin, or erythromycin. A three-day course of antibiotics was prescribed. Only Materials and methods fractures in the finger distal to the metacarpophalangeal From January 1, 1986 through January 31, 1988, all (MP) joint were included. Patients with damage to one open finger fractures referred to the senior author were or both digital vessels were excluded. Patients, under prospectively anaiyzed and randomly selected to be ei- regional or metacarpal block anesthesia, in both groups ther treated with or without antibiotics. A total of 91 were treated surgically with aggressive irrigation and Vol. 15A, No. 5 September 1990 Antibiotics in open fracture qf the jnger 763 Fig. 2. A, Open fracture and amputation distal phalangeal level long and ring finger. B, Wounds granulating at 3 weeks postinjury. C, Healed fingertips 1 year from injury date, with mild hook nail deformity. debridement . Forty-five of the 9 1 patients received oral Table I antibiotics and 46 did not. Nail bed injuries with as- sociated distal phalangeal fractures were treated with Antibiotics Fracture location wound closure, and amputations were left open. Four phalanx Yes No patients from each required internal fixation with Kirschner (K-)wires. Patients in the group receiving Distal 31 31 4 antibiotics and in the group that did not receive anti- Middle 4 Proximal 10 5 biotics had similar numbers of fractures in the distal, middle, and proximal phalanges (Table I). No patients were excluded from this study because of underlying diseases such as diabetes or peripheral vascular disease. fracture healed primarily. His range of motion is shown Likewise, no patients were excluded because of poten- in Figs. 1, C and D at 3 months after injury. tial bacterial contamination. Two farmyard injuries Fig. 2, A shows a 25year-old man who sustained an were included in the group receiving antibiotics and amputation of the long and ring finger at the distal one in the group that did not receive antibiotics. phalangeal level in an industrial press. His wounds were Fig. 1, A shows an 18-year-old right-handed high irrigated and debrided in the emergency room and al- school student who was involved in a motor vehicle lowed to granulate; he was placed into the group not accident in which he sustained open fractures of the receiving antibiotics. Fig. 2, B shows the wound at 3 middle phalanx to the ring finger with extensor tendon weeks, and Fig. 2, C shows a healed wound at 1 year, laceration. There was an associated nail bed injury with mild hook nail deformity. The patient has returned with open fracture of the distal phalanx of the small to work without pain or restriction. finger. Results Fig. 1, B shows the x-ray films before and after intraosseous wire stabilization of the fracture. He was A total of eight patients, four from the treated and included in the group not receiving antibiotics, and his four from the untreated group had development of clin- The Journal of 764 Suprock, Hood. and Lubahn HAND SURGERY ical signs of infection, such as drainage or throbbing when compared with a group of patients treated with pain that were not relieved by elevation of the extremity aggressive irrigation and debridement alone. There was and oral analgesics. In each of these patients the onset no difference in the incidence of infection from the of symptoms was in the second postoperative week. proximal, middle, or distal phalanges, and in this small Antibiotics that had been previously used were re- series there was no difference in the incidence of in- started. A cephalosporin was started in the four patients fection when Kirschner wires were used for internal who were previously untreated. Within the group of fixation. Early treatment with antibiotics may play a eight patients, there were four (two from each group) role in helping prevent infections of the fingers in pa- in whom purulent drainage developed and cultures were tients who have significant amounts of devitalized tissue taken. Cultures of the purulent drainage from the an- or who are noncompliant in follow-up care. tibiotic-treated group grew Staphylococcus aureus, and The authors acknowledge Phyllis Kuhn, PhD, and Diane the two cultures from the previously untreated group Voelker, Research Department, Hamot Medical Center for were negative. Oral cephalosporins were used exclu- editing and typing this manuscript. sively in this group of eight patients. REFERENCES There were no patients in either group who required 1. Patzakis MJ, Harvey JP, Ivler D. The role of antibiotics secondary surgical procedures, and no cases of osteo- in the management of open fractures. J Bone Joint Surg myelitis. Only 8.4% (8 of 9 1) of all patients had clinical 1974;56A:532-41. signs of infection and 2.1% (2 of 91) had cultures that 2. Gustilo RB, Anderson JT. Prevention of infection in the grew Staphylococcus aureus. The clinically-infected treatment of one thousand twenty-five open fractures of fingers accounted for 4.2% (4 of 91) of both the long bones. J Bone Joint Surg 1976;58A:453-8. antibiotic-treated group and the nonantibiotic treated 3. Burkhalter WE, Butler B, Metz W, Omer G. Experiences group. with delayed primary closure of war wounds of the hand in Viet Nam.
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